Breast Reconstruction

Breast Reconstruction - Page

Each year more than 250,000 American women face the reality of either invasive or noninvasive breast cancer. New kinds of treatment, new legislature regarding insurance coverage, as well as improved reconstructive surgery means that women who have breast cancer today have more choices. Dr. Rex Moulton-Barrett offers advanced breast reconstruction in Alameda and Brentwood to restore each patient’s appearance and self-image.

About Breast Cancer

The risk of developing breast cancer increases with age. About 1 out of 8 invasive breast cancers are found in women younger than 45, while about 2 out of 3 with invasive breast cancers are found in women age 55 or older.

Certain inherited DNA changes may increase the risk for developing cancer and are responsible for the cancers that run in families. For example, the BRCA genes (BRCA1 and BRCA2) are tumor suppressor genes. Mutations in these genes may be inherited. When mutated, they no longer suppress abnormal growth, and cancer is more likely to develop. Genetic testing may identify women with inherited mutations in the BRCA1 or BRCA2 tumor suppressor genes (or less commonly in other genes such as PTEN or p53.

However, most breast cancer DNA mutations occur in single breast cells during a woman’s life, rather than inherited. These acquired mutations of oncogenes and/or tumor suppressor genes may result from other factors, such as radiation or cancer-causing chemicals. But so far, the causes of most acquired mutations associated with breast cancer remain unknown. Most breast cancers have several gene mutations that are acquired. Tests to spot acquired gene changes may help doctors more accurately predict survival of women with breast cancer. For example, tests to identify women whose breast cancer cells have too many copies of the HER2 oncogene. These cancers tend to be more aggressive.

The risk of contra-lateral (the opposite breast) breast cancer must be taken into consideration prior to embarking on breast reconstruction. Genetic factors, specifically the BRCA 1&2 genes and histological factors, specifically the finding of lobular carcinoma and previous chest wall irradiation are associated with a higher risk for contra-lateral carcinoma. Treatment with suppression hormone therapy may also have an influence on the risk of developing contra-lateral disease. Similarly, the use of hormone replacement therapy may increase recurrence rate and possibility of developing cancer in the opposite breast. In one recent study, positive family history: parent more than one sister and then maternal age of first pregnancy specifically over age 25 were associated with an increased risk of developing breast cancer.

Risk scores have been developed to help determine the likelihood of developing breast cancer: CARE (Contraceptive and Reproductive Experience), BCRAT( Breast Cancer Risk Assessment Tool) and BCDD (Breast Cancer Detection and Demonstration Project). It seems the calculated risks vary widely according to ethnic differences and the individual study criteria.

Conservation surgery refers to removal of a part of the breast. Examples of breast conservation surgery include lumpectomy or segmental mastectomy. Lumpectomy may lead to a significant asymmetry in breast size and shape. A breast reduction on the opposite should be a covered insurance benefit and may restore symmetry. But, some women choose or are advised to undergo a mastectomy, which removes the entire breast. Many women who have a mastectomy choose reconstructive surgery to restore the breast’s appearance.

Legal rights for breast reconstruction in the USA as part of a covered insurance benefit are well defined. In 2007 The Breast Cancer Protection Act was approved in the US House of Representatives. This allowed patients following mastectomy to remain in hospital a minimum of 48 hours following surgery. The Women’s Health and Cancer Rights Act of 1998, provides for reconstruction of the affected breast and the contra-lateral breast to provide symmetry. The Bill is effective for all health plans and also includes prostheses and the treatment of post-mastectomy arm edema. However, there is no requirement for the insurance carrier to provide reconstruction for patient who underwent mastectomy prior to 1998.

Planning Your Breast Reconstruction

If you are thinking about having reconstructive surgery, it is a good idea to talk to your oncologist, breast cancer surgeon and a plastic surgeon before your mastectomy. This allows the surgical teams to plan a treatment best individualized for you, even if you decide to wait to have reconstructive surgery later. Immediate reconstruction is performed at the same time as the mastectomy. One advantage to having immediate breast reconstruction, is that it means one less surgery.

Immediate reconstruction techniques may still require a number of procedures after mastectomy to complete the process. Even if you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take. The decision to perform immediate breast reconstruction without full knowledge of the extent: termed ‘stage’ of the tumor remains controversial. That is, if radiation and chemotherapy are likely to follow surgery, is the additional risk of wound breakdown and fibrosis (scarring) with immediate reconstruction justified? According to some surgeons, radiation can be used with a tissue expander placed on the chest wall providing the expander is left in an unexpanded state until 6 months following completion of therapy. Others have noted no increased wound breakdown as a result of chemotherapy. My own view is one of ‘safest is best’.

Delayed reconstruction means that the rebuilding is started later. If radiation and chemotherapy are likely, why not wait and delay breast reconstruction, unless the psychological consequences of the disfiguration justify the potential increased risk of complications of breast reconstruction associated with chemo-radiation therapy.

Decisions about reconstructive surgery depend on many personal factors such as: your overall health, the stage of your breast cancer, the size of your natural breast, the amount of tissue available, whether you want reconstructive surgery on both breasts, the type of procedure you are contemplating, the size of implant or reconstructed breast, your desire to match the look of the other breast.

Decision – making – diagrams exist to help determine the best reconstruction choices. Simply put, if the chest wall is to be radiated or if there is insufficient remaining skin to the chest wall for expansion, autologous tissue ( your own tissue ) is preferable over placement of expanders and subsequent breast saline or silicone jel implants. If autologous tissue is chosen there are 3 major choices: 1. the lower abdominal pannus attached to one or both rectus abdominus muscles: transverse rectus abdominus muscle flap (TRAM flap), 2. the latissmus dorsi muscle with skin (LD) flap which usually requires an additional implant to provide adequate volume and finally 3. free tissue transfer of skin, fat and sometimes including muscle of which the most popular are the deep inferior epigastric perforator (DIEP), superficial epigastric perforator (SIEP), superior gluteal arterial perforator (SGAP) and inferior gluteal arterial perforator (IGAP) flaps. Free tissue transfer is usually performed at medical centers specializing in microsurgical procedures and the surgical time for these procedures may be extensive. I personally do not perform microsurgical free tissue transfer.

Tram Breast Reconstruction

In my practice, the TRAM flap is the workhorse of autologous breast reconstruction. However, in certain patient’s, it may not be appropriate. For example, in an overweight patient with a lower abdominal pannus measuring greater than 6cm from the rectus muscle to skin, in a smoker, a thin patient, a patient who has had an abdominoplasty or extensive abdominal liposuction or previous incisional surgery which divided the rectus abdminus muscle and in patients who do not wish for the additional scars or who are medically not fit for more prolonged procedures. Finally, there are those patients who would prefer not to loose any abdominal wall function and the free tissue transfer described below offers a muscle sparing advantage over the TRAM flap. The additional surgical time of free tissue transfer procedures may be reduced in centers specializing in free tissue transfer and when investigating this option, an important question to be answered is how long is the anticipated surgical time? My experience is that the addition of a TRAM flap to mastectomy adds about 3 hours to the procedure and a reduction or mastopexy (breast lift to the opposite breast) another 1 hour. I have found that the surgical time for mastectomy with TRAM and contra-lateral lift/reduction varies between 4-6 hours in total.

DIEP Flap

DIEP Flap

The DIEP flap employs skin and fatty tissue from the lower abdomen to restore the breast. The result in the abdomen is much like a tummy tuck in improving the abdominal contour. Because the DIEP procedure does not sacrifice the rectus abdominus muscle, full abdominal strength is preserved.

The “Stacked DIEP Flap” provides another option for the thin woman who needs reconstruction of only one breast. This procedure allows for more abdominal fatty tissue than conventional TRAM procedures or single DIEP flap procedures. It is possible to provide a greater volume to the reconstructed breast than has been historically possible. The “Stacked Flap” provides an opportunity to reconstruct using abdominal tissue in women who previously would not have been candidates.

SIEP flaps have a dominant blood supply which arises in the more superficial abdominal fatty tissue. The procedure is otherwise the same as the DIEP procedure and represents a second choice for women whose superficial vessels are more dominant than the deep inferior epigastric perforators.

SGAP Flap

IGAP Flap

SGAP & IGAP Flaps are most often used when there is otherwise inadequate lower abdominal skin and fat volume to reconstruct a breast. Skin and fat from the upper buttock and hip and the tiny feeding blood vessels are collected without loss of underlying muscle tissue. IGAP Flap is similar to the SGAP except that fat is collected from the lower hip and buttock. After removal of the fatty tissue from the upper hip area, a closure can be concealed within the line of undergarments. Bilateral breast reconstructions may be performed using bilateral GAP flaps simultaneously.

Chest wall expansion and subsequent implant placement is ideally performed following a relative skin sparing mastectomy in a non-irradiated chest wall. In order to avoid repeated visits to the operating room it is reasonable to place an expander at the time of mastectomy. The decision to remove the expander if irradiation is necessary is one to be made between the patient and reconstructive surgeon. My own preference is to remove the expander and wherever possible use autologous tissue 3-6 months after completion of irradiation therapy.

Mentor Siltex textured low profile saline expanders

Chest wall expanders are designed to provide skin expansion where it is most needed. The newer horizontal comma shaped expanders provide for lower pole fullness and avoid over expansion higher up – under the clavicle. At the time of expander placement, the pectoral muscle is lifted to place the upper half of the expander directly over the rib cage and under the muscle. Typically, this means the lower 1/3-1/2 of the expander has only skin subcutaneous fat overlying it. For this reason over others, silicone jel implants are preferable over saline at the time of exchange from expander to implant. The jel implants are less likely to ripple and feel irregular in their contour in the face of the very thin skin envelope in the lower 1/2 of the reconstructed breast. The time interval between placement of the expander and completion of expansion is typically 3 months, but this may be shorter providing the patient’s comfort during a more rapid expansion not an issue as well as the ability of the chest wall skin to expand without damaging the skin and muscle blood supply.

The type of incision used to perform mastectomy is also an area of some controversy. Some surgeons perform a skin sparing incision which removes only the skin of the areola and nipple. The entire mastectomy is performed within this circular incision. Simultaneous implant placement may then be performed by lifting the pectoral muscle and suturing it to the lower border of of the peri-areola skin. The peri-areolar skin is then purse-stringed into a gathering. This purse-stringed area can later be utilized in the nipple reconstruction. Other surgeons feel the purse-string contour is not as natural as if when an ellipse of skin is removed across the chest wall. Clearly, in individuals prone to hypertrophic scarring, the smaller the incision the better, regardless of minor contour irregularities. The focus on skin sparing mastectomy should never override tumor control. That is, if there is any doubt that the previous biopsy site is indeed clear of tumor, then the overlying skin should be excised and a more traditional ellipse of skin is excised. There are patients in whom it is better to perform an excision of the entire skin over the mastectomy. For example, damaged, or previously irradiated skin with considerable burn or scar may be unsuitable for skin sparing reconstruction. Alternatively, if a flap is being utilized, it may look more natural to fold the skin of the flap at the infra-mammary crease to create the natural ptosis of the lower pole of the breast, this means excising skin of the chest wall skin above the infra-mammary crease.

Ellipse Technique

Purse String Technique

Following completion of the breast mound creation by flap or implant, nipple aroela reconstruction is usually performed as the last stage of the reconstruction. This final stage may be performed in the clinic, operating room or in the hospital or outpatient surgery center. I usually start by tattooing the planned area for the areola and within the tattooed area a 3 pointed star is drawn out. The central arm of the star is elevated with a mound of subcutaneous fat from point above to widened base below. The 2 side arms on either side of the central arm are elevated just deep to skin and are sutured to the opposing side of the central arm, like wrapping arms around a waist. Then the site from which these arms was taken is sutured close and the area is again tattooed to recreate the circular pattern of pigmented areola.